cancellation-request | Access One Insurance & Tax

I, the above named individual, give my permission to Access One Insurance to serve as the licensed health insurance agent/broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Licensed Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1. Searching for an existing Marketplace application. 2. Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums. 3. Providing ongoing account maintenance and enrollment assistance, as necessary; or 4. Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the Licensed Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Licensed Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Licensed Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect for 36 months or until I revoke it, and I may revoke or modify my consent at any time in writing.

Finding the Right Healthcare For You!

Cancellation Request / Change of Address

AOI Client Cancellation_English

CANCELLATION REQUEST - Part 1

CANCELLATION CONSENT - Part 2

Administrative Information - Do Not Change

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